Stepping down for mild asthma and disadvantages of the ‘as‐needed’ strategy—Perspectives from a developing country

Abstract

Stepping down for well-controlled asthma is crucial to achieve the lowest effective inhaled corticosteroid (ICS) dose. However, recommendations for stepping down are still ambiguous, particularly regarding the step-down strategy in patients with well-controlled asthma treated with once-daily low-dose ICS/long-acting beta2-agonist (LABA) combination. The 2021 Global Initiative for Asthma (GINA) guideline recommended ‘as-needed’ low-dose ICS-formoterol (ICS-FOR) as a therapeutic option for Step 2 asthmatics among adolescents and adults.1 Whether patients whose asthma is well controlled with once-daily low-dose ICS/LABA could be stepped down to ICS-FOR as needed is still an open question because: (1) as-needed therapy is inconsistent with the previous preventive purpose of GINA guidelines and (2) it has the potential risk of poor outcomes if not enough ICS are taken. To circumvent disadvantages of the as-needed strategy, we have suggested the scheduled University Medical Center (UMC) step-down strategy for well-controlled mild asthma with daily low-dose ICS or once-daily low-dose ICS/LABA (one inhalation every other day → two inhalations a week → one inhalation a week).3 Each step of the step-down process will be applied as a trial if an asthma patient achieves well-controlled, stabilized pulmonary function for at least 3 months.3 The pre-existing dose would be prescribed if loss of asthma control appeared to be induced by insufficient ICS dosing. A randomized controlled trial to compare the UMC strategy and the as-needed strategy has been planned. In conclusion, the as-needed ICS-FOR strategy could be helpful to avoid treatment with short-acting beta2-agonist only in mild asthma, but its indication should be considered carefully and balanced against characteristics of individual patients and their country setting. The recommendation of as-needed ICS-FOR as an option for stepping down requires more evidence. We thank Dove Medical Press Ltd. (the original publisher of figure 1) for granting permission to re-publish this figure. None declared.